Los Angeles is heading for catastrophe.
An explosion of COVID-19 patients has begun to flood hospitals and may soon force doctors to ration care. The number of beds available in intensive care units is rapidly dropping to zero, as health professionals implore people not to go to the emergency room unless it is a matter of life and death.
“Ambulances are circling hospitals for hours trying to find one that has an open bed so they can bring their seriously ill COVID patient out of breath,” said a doctor at a public hospital in LA County last week, describing the “apocalyptic” scene . “We are literally hanging by a thread.”
And there are no signs of extension. The number of patients with COVID-19 in hospitals is expected to grow by January – or beyond, if Christmas trips and social gatherings foster the spread of the virus.
If there is another wave in a few weeks, “it will result in visions of northern Italy-cut-New York from people in the corridors,” Los Angeles Mayor Eric Garcetti said in an interview. “We are about to do that.”
The dire situation has created confusion and discouragement among the angelics, many of whom are wondering if their sacrifices in the past nine months have been in vain. LA County was one of the first to adopt the masks, quickly instituted home stay orders in March and November, and has so far kept its rate of coronavirus cases and deaths from COVID-19 relatively low.
So, what went wrong?
Interviews with 31 epidemiologists, health experts and public officials offer clues: LA was far more vulnerable to an extreme crisis than anywhere else in the country.
The triad of fatigue, winter weather and holiday travel that led to more transmission of coronavirus across the country also hit here – and became the match that lit the gunpowder box.
The popular image of LA – hillside mansions, urban sprawl and chauffeured drivers in their cars – belies the harsh reality. LA County, which is home to more than 10 million people, suffers from high rates of poverty and homelessness, large numbers of essential workers and some of the densest neighborhoods in the country.
“There is no city as big and complex as LA. The closest may be New York. And we saw what happened in New York, ”said Dr. Kirsten Bibbins-Domingo, an epidemiologist at UC San Francisco.
Experts also attribute LA’s problems to rules that may seem inconsistent or arbitrary, as well as to a confusing patchwork of policies across Southern California. In addition, the county is investigating whether a more contagious strain of the virus, circulating in the United Kingdom, could be partly to blame.
LA for the most part has taken the right steps, according to epidemiologists, and with a little luck, has managed to contain a crisis for months.
“Now, some of that luck is gone,” said Garcetti.
November brought a wave
An increase in coronavirus cases that began in early November put LA county officials on alert.
On Thanksgiving week, 4,000 people tested positive each day, at the time a record for the county. LA County Public Health Director Barbara Ferrer thought the numbers had probably peaked.
Then Thanksgiving came.
“We realized, ‘Oh, my God. We have everyone traveling, as hundreds of thousands of people are traveling, ‘”she said in an interview last week. “At that point, we were very frightened, because we simply knew in our hearts that we were heading for one wave after another.”
LA County now has an average of 14,000 new coronavirus cases per day.
The coronavirus took off across California in November, the start of a peak that had been predicted months earlier. The progression reflected that of the 1918 influenza pandemic in the United States, when the peak of autumn was five times greater than that of spring.
Coronavirus is believed to thrive in colder, drier climates, making transmission more likely during this time of year. Short winter days can also cause people to spend more time indoors, where the virus can spread easily.
Until November, California prevented the big outbreaks that broke out in other parts of the country, so once the virus started to circulate more, a larger proportion of the state’s population may have been susceptible, experts say. In addition, because they have not seen so much initial devastation at first hand, Californians may have had a false sense of confidence that the pandemic was controllable.
“People get tired,” said Dr. Grant Colfax, San Francisco’s director of public health. “It was a long 10 months and I think people started to let their guard down a little bit more, because we were in relatively good shape.”
A high ‘social vulnerability’ score
As the broadcast increased in the fall, LA faced unique challenges.
LA County has a huge manufacturing sector and two of the country’s largest ports – industries operated by people working in closed environments that can facilitate the spread of the virus. LA factories – where individual outbreaks have infected more than 400 people – have been the main cause of cases during the pandemic.
LA County also has a high “Social vulnerability” score as calculated by the United States Centers for Disease Control and Prevention, a measure of how severely a region can be affected by a natural disaster or disease outbreak, based on factors including average income, education and housing. The county’s score is worse than anywhere in the Bay Area or in the neighboring counties of Ventura and Orange, suggesting that it will always be harder for LA to withstand a wave of COVID-19 without deadly consequences.
“This is what we want: that Los Angeles has the combination of poverty and density that makes a virus like this able to spread much more quickly and be more devastating,” said Garcetti.
LA’s expensive housing market has also hurt the region. While density measures how many people live in a geographic area, another metric, known as “agglomeration”, tracks how many people live in a home. Having more than one person per room, excluding bathrooms, is considered overcrowding.
But in LA, it is common for a working class family of four, five or more to share an expensive one-bedroom apartment.
Among the 25 largest metropolitan areas in America, LA has the highest percentage of overcrowded homes, according to 2019 data from the US Census Bureau. Eleven percent of Los Angeles homes are considered overcrowded, compared to about 6% in New York and the bay area.
An analysis published in June in the Journal of the American Medical Assn. found that the chances of falling ill due to coronavirus were not significantly affected by a person’s neighborhood poverty rate or density, but clearly increased as overcrowding increased. A cramped home may have no place for an infected person to isolate to prevent others from becoming ill.
“The more people you infect, and the denser people are staying, the more connections there will be,” said UC San Francisco epidemiologist Dr. George Rutherford.
In a county the size of Los Angeles, this spread has turned into “exponential growth”, with each new person infected making it more likely that other people will be infected, said Ferrer. Currently, it is estimated that 1 in 95 people in the county are infectious with the coronavirus.
‘I don’t think people are listening’
Ferrer is now focusing on breaking the transmission cycle. His department has banned dinners at open-air restaurants and state officials have issued a regional home stay order that lasts until the holiday. But she knows she has lost some public confidence in the past few months.
In the spring, “I drove to work every day and there were, like, two cars on the road – nobody was out. And we definitely don’t have it this time, ”said Ferrer. “I don’t think people are listening that much.”
Ferrer said the differing opinions of local elected officials that have emerged in recent months have eroded compliance with regulations. Two members of the county council of supervisors, Kathryn Barger and Janice Hahn, criticized the Department of Public Health for pushing the ban on outdoor dining. The three other supervisors and Garcetti supported public health officials.
“As soon as there is a feeling that there is no unity – that we are not all speaking with one voice – it also creates a different kind of confusion and, in some cases, creates many challenges,” said Ferrer. “This is a disaster for us.”
In San Francisco, where authorities report that new daily cases of coronavirus have begun to stabilize, visits to stores and recreational facilities have dropped 55% compared to the baseline, according to Google’s COVID-19 Community Mobility Report . In LA County, they fell just 24%.
Some experts suggest that the decrease in LA’s adherence to public health guidelines may be due to overly strict rules that sowed distrust among an audience that previously adhered to it. The controversial recent closure of playgrounds (later reversed) and the ban on small outdoor meetings, while domestic retail remains open, has generated criticism that decisions are being driven by the economy rather than public health considerations.
“Meetings with masks on the outside are a very low-risk activity and therefore restricting that, I think, is wrong,” said Leo Beletsky, professor of health sciences at Northeastern University. “There have been a number of cases where the restrictions have not been adapted to the evidence and have not been communicated clearly, which has opened the door to disinformation.”
Ferrer and other experts defended rules to reinstate the ban on most meetings, pointing out that it is clear that when people are not mixing, new infections decrease. She acknowledged, however, that it is a complicated message to explain that activities considered OK a few months ago are no longer safe, due to the large number of people who are sick.
In general, the rules in place during the pandemic helped LA a lot, said Ferrer – a view that many experts agree with.
While LA case numbers are astronomical, this is partly due to widespread testing, making it difficult to compare the region with other parts of the country, she said. When it comes to cumulative mortality rates, which are less influenced by the availability of tests, 93 out of every 100,000 people in LA County died of COVID-19, less than 134 in Illinois, 121 in Arizona and 103 in Florida. If LA County were a state, it would be 28th in terms of death rate.
The death toll in LA remains far from New York’s calamity in the spring. New York City reported nearly 25,000 COVID-19 deaths in total, compared to 9,400 in LA County.
But Ferrer knows that this could change soon. The sound of sirens became the soundtrack for the holiday weekend in parts of Los Angeles, while hospitals were packed with COVID-19 patients. Early data shows high travel rates last week, suggesting that a devastating, even worse, wave is approaching.
Governor Gavin Newsom has already ordered 5,000 body bags, most of which go to Los Angeles County.